INSTRUCTIONS WEST VIRGINIA DEPARTMENT OF HEALTH AND HUMAN RESOURCES APPLICATION / REDETERMINATION

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1 INSTRUCTIONS 1. You must use a pen when answering the questions. DO T use a pencil. 2. This form is designed to be completed by you. You may have a friend or relative help you with this form, but YOU are responsible for the information provided on the form. If you need additional help completing this form, leave the items blank and a Worker will assist you. 3. You can authorize someone outside your household to apply for Supplemental Nutrition Assistance Program (SNAP) and/or use your benefits for you. If you wish to designate such a person, please list the person you authorize on page 22. TE: This person may or may not live with you. 4. If you make a mistake, please draw a line through the mistake, and then write the correct answer. Initial the corrected answer. $ DM For Example: Income - $ The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, gender, religion, age, disability, political beliefs, sexual orientation, or marital or family status. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication or program information (Braille, large print, audiotape, etc.) should contact USDA s TARGET Center at (202) (voice and TDD). To file a complaint of discrimination, write to USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, DC or call (800) or (202) (TDD). USDA is an equal opportunity provider and employer. WEST VIRGINIA DEPARTMENT OF HEALTH AND HUMAN RESOURCES APPLICATION / REDETERMINATION The application will be considered if it contains a minimum of the Name, Address, and Signature below. The amount of SNAP benefits will be determined from the date of application. The amount of cash assistance will be determined from the date eligibility requirements are met, including signing the Personal Responsibility Contract (PRC) and participating in orientation. I understand that it is a criminal violation of federal and state law to provide false or misleading information for the purpose of receiving benefits to which I am not by law entitled. I understand my responsibility to provide complete and truthful information. Person Providing Information: (First Name) (MI) (Last Name) (Signature) (Date) If you are not the person requesting assistance, do you live in the home with the applicant? Applicant(s) Name if Different From Above: (First Name) (MI) (Last Name) (Signature) (Date) (First Name) (MI) (Last Name) (Signature) (Date) 1

2 Address where applicant lives: HOUSE NUMBER STREET CITY STATE ZIP CODE Mailing Address if different: HOUSE NUMBER STREET CITY STATE ZIP CODE Telephone Number where the applicant can be reached: (Area Code) + (Phone Number) Directions to the home (please be specific): Name and address of a relative or friend to contact should it be necessary: NAME ADDRESS RELATIONSHIP TELEPHONE NUMBER SECTION I - BENEFIT INFORMATION Are you a resident of West Virginia? Are you currently receiving benefits? If yes, from what State/County? If yes, what benefits? In whose name do you receive these benefits? Have you received benefits in the past in West Virginia? If yes, what type and when? In whose name did you receive these benefits? Are you currently residing in a shelter for battered women? Have you moved from another state? If yes, what State/County? Date Moved: Were you receiving benefits from that state? If yes, what type and when? In whose name did you receive those benefits? 2

3 SECTION II - EXPEDITED SERVICES You may qualify for expedited processing of your SNAP application. If eligible, this means that you will receive benefits no later than seven (7) days after the date you apply. Answers to the following questions will determine if you qualify for this service. A) Have you received SNAP benefits this month? If so, are you staying in a shelter for battered women? B) How much do you have in cash and/or bank accounts? $ C) What is your household s monthly income before any deductions? $ D) How much is your rent/mortgage each month? $ E) Are you obligated to pay a utility expense? If yes, are you or anyone who lives in your residence obligated to pay a heating or cooling cost? F) Is anyone in your household a migrant and/or seasonal worker? SECTION III - HOUSEHOLD COMPOSITION Complete a box for each person who lives in your home. Complete all information for each person. Begin with YOURSELF on Page 4. If MORE THAN five (5) persons are in the home, extra sheets are available. TE: For Nursing Home or other specialized medical care, complete for YOURSELF and YOUR SPOUSE and DEPENDENTS in the home. Citizen/Alien/Age Declaration I certify under penalty of perjury, by signing my name below, that I am a United States Citizen or alien in lawful immigration status. This declaration of citizenship or alien status is a condition of eligibility for WV WORKS, Medicaid, and SNAP. Any household member for whom citizenship is not declared is not eligible to receive benefits. However, his income and assets will be considered available to the remaining members of the household. / / Name (month) (day) (year) III.A - Applicant Information 3

4 Applicant s Legal Name: First Middle Last Social Security Number (SSN): If you do not have a SSN, list the date you applied: Applicant s Birthdate: Are you known by any other name(s)? If yes, list other name: Marital Status (please check one): Single/Never Been Married Married Divorced Separated Widowed If you are under age 18, have you been declared an adult? United States Citizen? If no, complete the following: INS Number: Country of Citizenship: U.S. Entry Date: Sponsor Name: Sponsor s Address: Alien Status: Alien Status Date: Do you speak English? If no, what language do you speak? Are you currently attending school? If yes: Full-time Part-time Name/Address of School: Do you have a High School diploma or GED equivalent? If no, last grade you completed: K Did you have any schooling after High School or GED? If yes, do you hold any degrees, licenses or certificates? Please specify: Do you receive any of the following? SSI If, date began: Foster Care If, date began: Adoption Assistance If, date began: Do you intend to reside in WV? Are you under the control of the courts and work without pay? If you are not a parent, are you acting as a parent to anyone under age 18 who is not a biological or adopted child? 4

5 III.B - Co-Applicant / Other Household Member Legal Name: First Middle Last Social Security Number (SSN): / / If this person does not have a SSN, list the date this person applied: Birthdate: Relationship to Applicant: Is this person known by any other name(s)? If yes, list other name: Does this person live with you? If no, where does this person live? Marital Status (please check one): Single/Never Been Married Married Divorced Separated Widowed If under age 18, has this person been declared an adult? United States Citizen? If no, complete the following: INS Number: Country of Citizenship: U.S. Entry Date: Sponsor Name: Sponsor s Address: Alien Status: Alien Status Date: Does this person speak English? If no, what language is spoken? Is this person currently attending school? If yes: Full-time Part-time Name/Address of School: Does this person have a High School diploma or GED equivalent? If no, last grade completed: K Did this person have any schooling after High School or GED? If yes, does this person hold any degrees, licenses or certificates? Please specify: Does this person receive any of the following? SSI If, date began: Foster Care If, date began: Adoption Assistance If, date began: Does this person intend to reside in WV? Is this person under the control of the courts and working without pay? Is this person acting as a parent to anyone under age 18 who is not a biological or adopted child? III.B - Other Household Member 5

6 Legal Name: First Middle Last Social Security Number (SSN): / / If this person does not have a SSN, list the date this person applied: Birthdate: Relationship to Applicant: Is this person known by any other name(s)? If yes, list other name: Does this person live with you? If no, where does this person live? Marital Status (please check one): Single/Never Been Married Married Divorced Separated Widowed If under age 18, has this person been declared an adult? United States Citizen? If no, complete the following: INS Number: Country of Citizenship: U.S. Entry Date: Sponsor Name: Sponsor s Address: Alien Status: Alien Status Date: Does this person speak English? If no, what language is spoken? Is this person currently attending school? If yes: Full-time Part-time Name/Address of School: Does this person have a High School diploma or GED equivalent? If no, last grade you completed: K Did this person have any schooling after High School or GED? If yes, do you hold any degrees, licenses or certificates? Please specify: Does this person receive any of the following? SSI If, date began: Foster Care If, date began: Adoption Assistance If, date began: Does this person intend to reside in WV? Is this person under the control of the courts and working without pay? Is this person acting as a parent to anyone under age 18 who is not a biological or adopted child? III.B - Other Household Member Legal Name: 6

7 First Middle Last Social Security Number (SSN): / / If this person does not have a SSN, list the date this person applied: Birthdate: Relationship to Applicant: Is this person known by any other name(s)? If yes, list other name: Does this person live with you? If no, where does this person live? Marital Status (please check one): Single/Never Been Married Married Divorced Separated Widowed If under age 18, has this person been declared an adult? United States Citizen? If no, complete the following: INS Number: Country of Citizenship: U.S. Entry Date: Sponsor Name: Sponsor s Address: Alien Status: Alien Status Date: Does this person speak English? If no, what language is spoken? Is this person currently attending school? If yes: Full-time Part-time Name/Address of School: Does this person have a High School diploma or GED equivalent? If no, last grade you completed: K Did this person have any schooling after High School or GED? If yes, do you hold any degrees, licenses or certificates? Please specify: Does this person receive any of the following? SSI If, date began: Foster Care If, date began: Adoption Assistance If, date began: Does this person intend to reside in WV? Is this person under the control of the courts and working without pay? Is this person acting as a parent to anyone under age 18 who is not a biological or adopted child? III.B - Other Household Member Legal Name: First Middle Last 7

8 Social Security Number (SSN): / / If this person does not have a SSN, list the date this person applied: Birthdate: Relationship to Applicant: Is this person known by any other name(s)? If yes, list other name: Does this person live with you? If no, where does this person live? Marital Status (please check one): Single/Never Been Married Married Divorced Separated Widowed If under age 18, has this person been declared an adult? United States Citizen? If no, complete the following: INS Number: Country of Citizenship: U.S. Entry Date: Sponsor Name: Sponsor s Address: Alien Status: Alien Status Date: Does this person speak English? If no, what language is spoken? Is this person currently attending school? If yes: Full-time Part-time Name/Address of School: Do you have a High School diploma or GED equivalent? If no, last grade you completed: K Does this person have a High School diploma or GED equivalent? If yes, do you hold any degrees, licenses or certificates? Please specify: Does this person receive any of the following? SSI If, date began: Foster Care If, date began: Adoption Assistance If, date began: Does this person intend to reside in WV? Is this person under the control of the courts and working without pay? Is this person acting as a parent to anyone under age 18 who is not a biological or adopted child? III.B - Other Household Member Legal Name: First Middle Last Social Security Number (SSN): / / 8

9 If this person does not have a SSN, list the date this person applied: Birthdate: Relationship to Applicant: Is this person known by any other name(s)? If yes, list other name: Does this person live with you? If no, where does this person live? Marital Status (please check one): Single/Never Been Married Married Divorced Separated Widowed If under age 18, has this person been declared an adult? United States Citizen? If no, complete the following: INS Number: Country of Citizenship: U.S. Entry Date: Sponsor Name: Sponsor s Address: Alien Status: Alien Status Date: Does this person speak English? If no, what language is spoken? Is this person currently attending school? If yes: Full-time Part-time Name/Address of School: Does this person have a High School diploma or GED equivalent? If no, last grade you completed: K Did you have any schooling after High School or GED? If yes, do you hold any degrees, licenses or certificates? Please specify: Does this person receive any of the following? SSI If, date began: Foster Care If, date began: ( Adoption Assistance If, date began: Does this person intend to reside in WV? Is this person under the control of the courts and working without pay? Is this person acting as a parent to anyone under age 18 who is not a biological or adopted child? SECTION IV - BENEFIT QUESTIONS Please check the box beside the benefit(s) you want to receive: WV WORKS (Cash Assistance) MEDICAID (MA/Medical Card) LIEAP (Low Income Energy Assistance, when available) EA (Emergency Assistance) CHIP (Children s Health Insurance Program) 9

10 NEMT (Non-Emergency Medical Transportation) SNAP (Supplemental Nutrition Assistance Program) Have you or any member of your household had any unpaid medical expenses in any of the past three (3) months? If yes, do you wish to have your Medical Card backdated to cover these expenses? Indicate Starting Date: Is there anyone in your home who is not purchasing food and preparing meals with you? If yes, who and why? SECTION V - INDIVIDUAL QUESTIONS Is anyone in your household pregnant? If yes, who? What is the date that the pregnancy was medically confirmed? What is the pregnancy due date? Is this person expecting more than one child? If yes, how many? Is any adult unable to work due to disability, blindness, or incapacity? If yes, please list name: Name Reason Date disability/blindness/incapacity began: Has this person been Denied SSI/RSDI based on disability? If yes, has an appeal been filed? If so, when? Status of appeal: Is any child disabled or blind? If so, please list name: Name Reason Date disability/blindness/incapacity began: Has this child been Denied SSI/RSDI based on disability? Has this child been Denied SSI/RSDI based on parent s income or assets? Is this application for anyone who needs or is already receiving nursing home or other specialized medical care? If yes, who? Name State/County of Residence (Prior to Admittance) Date Admitted Facility Name: Facility Address: Is this person still residing there? 10

11 Is this person expected to return home within six (6) months of date of admission: Does he/she have a spouse living in the community? If yes, spouse s name/address: Does the person living in the nursing home or specialized care facility provide money to the spouse living in the community? If yes, how much? $ Is this application for the spouse of the above individual? Does the spouse also need or receive nursing home or other specialized medical care? If yes, name of spouse? Name State/County of Residence (Prior to Admittance) Date Admitted Facility Name: Facility Address: Is this person still residing there? Is this person expected to return home within six (6) months of date of admission: Does he/she have a spouse living in the community? If yes, spouse s name/address: Does the person living in the nursing home or specialized care facility provide money to the spouse living in the community? If yes, how much? $ Is anyone in your household who was an SSI recipient in the past not receiving SSI now? If anyone in your household is a child under the age of 13 months, was the child s mother eligible for and receiving Medicaid at the time of the child s birth? Has the child always lived with its mother? SECTION VI - HOUSEHOLD MEMBERS/LEGAL HISTORY Read each statement carefully and answer or to EACH statement. If you answer to a question, then list the name of the household member(s) to whom the answer applies. (1) Is any member(s) of your household violating their probation or parole? Member(s): 11

12 (2) Is any member(s) of your household currently fleeing from law enforcement officials? Member(s): (3) Has any member(s) of your household been convicted of receiving SNAP benefits because of lying or misrepresenting their identity (who they are) or their residence (where they live)? Member(s): (4) Has anyone in your household been convicted on or after 8/23/96 of trafficking $500 or more in Food Stamps/SNAP benefits? Member(s): (5) Has any member in your household been convicted of a felony offense which occurred on or after 8/23/96 and involved the possession, distribution, and/or use of a controlled substance? Member(s): (6) Has any member of your household been convicted in federal, state, or local court of exchanging Food Stamps/SNAP benefits for illegal drugs, firearms, ammunition, or explosives? Member(s): SECTION VII - ASSETS The following page lists items that are considered assets. Read these carefully and check or. TE - Your answer should be if: A. You or anyone living with you, including all children who live with you, have any of the assets listed below; B. Your name, or the name of anyone living in your home, is listed on any of the types of accounts listed below; and/or C. You or anyone living with you owns any of the assets listed below with someone who does not live in your home. 12

13 Beginning on the next page, if your answer is, supply the following information about the assets. If an asset is owned by more than one person, list all the owners and explain how the asset is divided. For example: Equally, One- Half, One-Third, etc. DO T COMPLETE SHADED AREAS ASSETS OWNER S NAME(S) LOCATION ACCOUNT NUMBER(S) Savings Accounts Checking Accounts Money Market ACredit Union t Cash on Hand Christmas Club Stocks CURRENT VALUE HOW DIVIDED 13

14 Bonds/Savings BCertificates d of Deposit Trust Funds IRA/Keogh Profit Sharing Escrow Account/ Home Sale Funeral/Burial Funds Burial Plots Livestock Business Equipment Property (Including Life Estates & Dower Rights) Homestead Property Non-Homestead Property Other Real Estate Mobile Home Farm/Tractor Equipment Mineral Rights Personal Collections Camper/Trailer ATV or 3-4 Wheeler Snowmobile Airplane Boat Other (Please list): Are any of the assets listed in the chart on the previous page not available to the owner? If yes, which assets and why? Are any of the assets listed in the chart on the previous page set aside for burial? If yes, which assets? Has anyone in your household received a lump sum payment in the last three (3) months? If yes, received from whom and for what reason? Date Received: Ongoing? Gross Amount: $ 14

15 Any Expenses involved? Type and Amount: Has anyone transferred or divested (disposed of), sold, or given away property, income, or any other asset, including vehicles or life insurance or established a trust fund within the last five (5) years (60 months)? If yes, name: Date of Transfer: Transferred to: Value of Asset: $ Amount Received: $ VEHICLES (Include ALL automobiles, motor homes, trucks, and/or motorcycles.) Does anyone in your household own a vehicle or is anyone in the process of purchasing one? If yes, complete the following section for each vehicle. If no, go to the next section titled LIFE INSURANCE. Year/Make/Model of Vehicle: Name(s) on Vehicle Registration: Is this vehicle in your possession? Amount owed: $ Is it licensed? License Number: State in which it is licensed: Do you have the right to sell this vehicle without the agreement of any other parties who share ownership? VEHICLES (Include ALL automobiles, motor homes, trucks, and/or motorcycles.) continued Year/Make/Model of Vehicle: Name(s) on Vehicle Registration: Is this vehicle in your possession? Amount owed: $ Is it licensed? License Number: State in which it is licensed: Do you have the right to sell this vehicle without the agreement of any other parties who share ownership? Year/Make/Model of Vehicle: Name(s) on Vehicle Registration: 15

16 Is this vehicle in your possession? Amount owed: $ Is it licensed? License Number: State in which it is licensed: Do you have the right to sell this vehicle without the agreement of any other parties who share ownership? Year/Make/Model of Vehicle: Name(s) on Vehicle Registration: Is this vehicle in your possession? Amount owed: $ Is it licensed? License Number: State in which it is licensed: Do you have the right to sell this vehicle without the agreement of any other parties who share ownership? Year/Make/Model of Vehicle: Name(s) on Vehicle Registration: Is this vehicle in your possession? Amount owed: $ Is it licensed? License Number: State in which it is licensed: Do you have the right to sell this vehicle without the agreement of any other parties who share ownership? 16

17 LIFE INSURANCE Does anyone in your household have life insurance? If, complete the following for each person who is insured. If, go on to the next section. Person Insured Owner of Policy Face Value Amount Insurance Company Date Policy Purchased Jointly Owned: How Divided? Cash Surrender Value Policy Number $ $ Person Insured Owner of Policy Face Value Amount Insurance Company Date Policy Purchased Jointly Owned: How Divided? Cash Surrender Value Policy Number $ $ Person Insured Owner of Policy Face Value Amount Insurance Company Date Policy Purchased Jointly Owned: How Divided? Cash Surrender Value Policy Number $ $ Person Insured Owner of Policy Face Value Amount Insurance Company Date Policy Purchased $ Jointly Owned: How Divided? Cash Surrender Value Policy Number $ SECTION VIII EARNED INCOME ONLY 17

18 Is anyone in your household employed or self-employed? If, complete the following for each person who is self-employed or employed. If, go to the next section titled UNEMPLOYMENT HISTORY. 1) Name of person who is employed: Job Title: Employer s Name: Employer s Address: Employer s Telephone Number: Employment Begin Date: How Often Paid? Every 2 Weeks Twice a Month Once a Week Once a Month Other (Specify): Number of Hours Worked each Pay Period: Gross Payment Amount: (For Pay Period As Stated Below) $ Are earnings expected to stop: Is so, when? 2) Name of person who is employed: Job Title: Employer s Name: Employer s Address: Employer s Telephone Number: Employment Begin Date: How Often Paid? Every 2 Weeks Twice a Month Once a Week Once a Month Other (Specify): Number of Hours Worked each Pay Period: Gross Payment Amount: (For Pay Period As Stated Below) $ Are earnings expected to stop: Is so, when? 3) Name of person who is employed: Job Title: Employer s Name: Employer s Address: Employer s Telephone Number: Employment Begin Date: How Often Paid? Every 2 Weeks Twice a Month Once a Week Once a Month Other (Specify): Number of Hours Worked each Pay Period: Gross Payment Amount: (For Pay Period As Stated Below) $ Are earnings expected to stop: Is so, when? Has anyone in your household refused employment or training for employment? If yes, who? Reason for refusal: 18

19 Date refused: Has anyone in your household been fired, lost, or quit a job in the last sixty (60) days? If yes, who? Reason for firing, loss, or quitting: Date job lost: If yes, number of hours worked per week before loss: Wages earned per week before loss: $ Has anyone in your household voluntarily reduced work hours to less than 30 hours per week? If yes, who? Reason for reduction: If yes, number of hours worked per week before reduction: Wages earned per week before reduction: $ Is anyone in your household on strike? If yes, who? Date strike began: Monthly earnings prior to strike: $ If anyone in your household receives rental income, does someone in the household manage the property? If yes, who? If yes, how many hours per week are spent managing this property? Amount received per month: $ Is anyone in your household currently self-employed, (such as farming, babysitting, etc) or been self-employed within last 3 months? If yes, what type of employment? Does the person receive income regularly? How Often Paid? Every 2 Weeks Twice a Month Once a Week Once a Month Other (Specify): Is this income from a new business of less than one year? How long has this person had this business? Gross Monthly Payment Amount: (For Period of Operation) $ Are there expenses related to this employment? If yes, Type and Amount? Is anyone in your household blind with work-related expenses? If yes, what type of expenses? Amount of Monthly expenses? $ SECTION IX - EMPLOYMENT HISTORY Complete the following for your last four (4) places of employment. Begin with your most recent employment and work back. Include odd jobs. 19

20 Applicant s Name: Name of Employer: Employer s Address: Job Title/Occupation: Reason No Longer Employed: Length/Dates of Employment From: To: Type of Employment: Part-Time Full-Time Temporary Hourly Wage: $ Name of Employer: Employer s Address: Job Title/Occupation: Reason No Longer Employed: Length/Dates of Employment From: To: Type of Employment: Part-Time Full-Time Temporary Hourly Wage: $ Name of Employer: Employer s Address: Job Title/Occupation: Reason No Longer Employed: Length/Dates of Employment From: To: Type of Employment: Part-Time Full-Time Temporary Hourly Wage: $ Name of Employer: Employer s Address: Job Title/Occupation: Reason No Longer Employed: Length/Dates of Employment From: To: Type of Employment: Part-Time Full-Time Temporary Hourly Wage: $ 20

21 EMPLOYMENT HISTORY continued Complete the following for all other household members. List the most recent two (2) places of employment. Co-Applicant s Name: Name of Employer: Employer s Address: Job Title/Occupation: Reason No Longer Employed: Length/Dates of Employment From: To: Type of Employment: Part-Time Full-Time Temporary Hourly Wage: $ Name of Employer: Employer s Address: Job Title/Occupation: Reason No Longer Employed: Length/Dates of Employment From: To: Type of Employment: Part-Time Full-Time Temporary Hourly Wage: $ Other Household Member s Name: Name of Employer: Employer s Address: Job Title/Occupation: Reason No Longer Employed: Length/Dates of Employment From: To: Type of Employment: Part-Time Full-Time Temporary Hourly Wage: $ Name of Employer: Employer s Address: Job Title/Occupation: Reason No Longer Employed: Length/Dates of Employment From: To: Type of Employment: Part-Time Full-Time Temporary Hourly Wage: $ 21

22 SECTION X - UNEMPLOYMENT BENEFIT HISTORY Has anyone in your household received Unemployment Benefits within the last 12 months? If yes, list who received the benefits and when. If no, please proceed to the next section titled Unearned Income. NAME RECEIVED FROM TO Has anyone in your household refused Unemployment Benefits within the last 12 months or had Unemployment payments stopped before benefits ran out? If yes, who refused the benefits and when? 22

23 SECTION XI - UNEARNED INCOME Please complete this section for EVERYONE who lives in your home. Check or and fill in the requested information. Does anyone in your household, including all children, receive any of the following income? INCOME SOURCE Adoption Assistance Annuities/Payments Assistance from Another State Black Lung Charitable/Contribution from Other Sources Child Support Spousal Support (Alimony) Dividends Foster Care or Guardianship Payments Interest Military or Other Allotment Money from Other Person(s) Non-LIEAP Energy Assistance Payments from Sale of Property Railroad Retirement Rent/Utility Supplement Non-HUD Supplement HUD Rent Supplement Royalties (Gas, Oil, etc.) Sick/Disability Benefits Social Security Supplemental Security Income (SSI) Trust Fund Payments Unemployment Compensation United Mine Workers (UMW) Veterans Benefits VA Compensation VA Pension Workers Compensation Permanent Temporary Other Retirement/Pensions Other: PERSON FOR WHOM INCOME IS RECEIVED INCOME BEFORE DEDUCTIONS HOW OFTEN RECEIVED BEGIN DATE SECTION XII - HIGHER EDUCATION Does anyone in your household receive educational aid? 23

24 If yes, Student s Name: Name of School: Is this student receiving a grant, scholarship, or participating in a work study program? If yes, Name of Grant, Scholarship or Work Study Program: Amount: $ Begin/End Date: From: To: SECTION XIII - ROOM AND MEALS Does anyone in your household RECEIVE MONEY for room and/or meals from another person? Does this individual pay for meals? Number of meals per day: Meals Payment Amount: $ Does individual pay for room? Room Payment Amount: $ Does anyone in your household PAY ANYONE else for room and meals? Room Payment Amount: $ Number of meals per day: Meals Payment Amount: $ Does payment include heating? Commercial Boarding Establishment? SECTION XIV - SUPPORT PAYMENTS/FEES Does anyone in your household pay anyone else to care for a dependent child or disabled/incapacitated adult so a household member can get to work or training/school or look for a job? If yes, for whom? If so, Care Provider s Name: Provider s Address: Payment Amount: $ How Often Paid? Every 2 Weeks Once a Week Other (Specify): Twice a Month Once a Month Does anyone in your household make any support payments to/for persons living in another household (child support/health insurance/medical cost? etc.) If yes, for whom? If yes, who makes payment? Is it court-ordered support? Legal Obligation Amount: $ Actual Payment Amount: $ Does anyone in your household, or an institutionalized individual, pay or is required to pay guardian, committee, power of attorney, or attorney fees? If yes, type of fee: To whom paid? 24

25 For whom paid? Amount: $ SECTION XV - MEDICAL EXPENSES Does anyone in your household who is 60 years of age or older, or is disabled have any medical expenses? Does anyone in your household have any unpaid medical expenses? If yes, are any of these expenses for the previous three months? 1. NAME: EXPENSE TYPE BILLED AMOUNT BILLED FOR/PAID FREQUENCY DATE OF SERVICE $ $ $ $ 2. NAME: EXPENSE TYPE BILLED AMOUNT BILLED FOR/PAID FREQUENCY DATE OF SERVICE $ $ $ $ SECTION XVI - MEDICAL/HEALTH INSURANCE/REIMBURSEMENTS Does anyone in your household have health insurance coverage? Names of persons covered: Who carries the insurance policy? Relationship to Owner: Insurance Provider s Name: Insurance Provider s Address: Group Name: Premium Amount $ How often paid? Policy Begin/End Date: From: To: Has anyone in your household voluntarily stopped health insurance for a child within the last six (6) month? If yes, for whom? How much was paid for the insurance that stopped? $ Is there anyone in the household who will not cooperate with obtaining medical support coverage? If yes, who? 25

26 1) Is anyone in the household entitled to or enrolled in Medicare Part A or Part B? If yes, who? Enrolled in Part A? If yes, begin/end date: From: To: Premium Amount: $ Enrolled in Part B? If yes, begin/end date: From: To: Premium Amount: $ Medicaid Claim Number: Railroad Retirement: 2) Is anyone else in the household entitled to or enrolled in Medicare Part A or Part B? If yes, who? Enrolled in Part A? If yes, begin/end date: From: To: Premium Amount: $ Enrolled in Part B? If yes, begin/end date: From: To: Premium Amount: $ Medicaid Claim Number: Railroad Retirement: Has anyone in your household been involved in an accident with a financial/insurance settlement pending? Does anyone in your household seek payment or reimbursement for travel expenses related to Medicaid? Travel Date: Provider: Reason for Travel: To: Expenses: $ Who Was Transported? SECTION XVII - SHELTER AND UTILITY EXPENSES Does anyone in your household have shelter and/or utility costs or does an institutionalized individual who intends to return home have shelter costs for maintaining a home or apartment Are you and/or your family currently homeless? If yes, have you incurred any shelter/utility costs? 26

27 If yes, do you elect to use the Homeless Shelter Standard Deduction? Fill in all the information about the following expenses: SHELTER EXPENSE PERSON S NAME WHO PAYS THE BILL Mortgage(s) $ Property Tax $ Rent $ Lot Rent $ Structure Insurance $ Special $ Mobile Home Loan $ Land Contract Payment $ Repair Costs $ Condo/Association Fees $ Escrow Account for Property Taxes and/or Insurance Other $ $ MONTHLY AMOUNT TO WHOM PAID Fill in all the information about the following expenses: DO T COMPLETE SHADED AREAS. UTILITY EXPENSE PERSON S NAME WHO PAYS THE BILL PRIMARY SOURCE OF HEATING OR COOLING (Indicate only one heat and cooling source) TO WHOM PAID 27

28 Gas (Natural) Yes No Propane Yes No LP Gas Yes No Fuel Oil Yes No Kerosene Yes No Coal Yes No Wood/Wood Products Yes No Electricity Yes No Water Sewer Trash Removal Telephone Other Yes No Does your household currently receive or will it receive a HUD Utility Allowance Yes No If yes, does the HUD Utility Allowance exceed utility expenses? Yes No Does anyone who is T in your household pay any expenses/bills for you or anyone in your home? If yes, what expense? How much is paid? $ Who pays the expense(s)? Does anyone who is T in your household give you or anyone in your home money to pay any bills? If yes, how much? $ Who gives you the money? SECTION XVIII LOW INCOME ENERGY ASSISTANCE PROGRAM (LIEAP) Do you pay to heat your home? Do you or have you ever received (LIEAP) payments? If yes, when? To: Does your household request regular LIEAP assistance? Does your household request emergency LIEAP assistance? 28

29 Does your household wish to be evaluated for an automatic issuance of LIEAP if you are determined eligible? SECTION XIX SCHOOL CLOTHING ALLOWANCE (SCA) Does your household wish to be evaluated for an automatic issuance of SCA If you are determined eligible? SECTION XX EMERGENCY ASSISTANCE Do you have an eviction or foreclosure notice? If yes, how much is needed to avoid the eviction/foreclosure? $ Do you have a notice of utility service termination? If yes, what utility or utilities? Are you without bulk fuel? If yes, how much is needed for a 30 day supply of fuel? $ Are you in need of telephone service and everyone who lives in your home is 65 years of age or older, or is disabled or temporarily incapacitated for at least the next 30 days? Are you without any food? Are you in need of shelter, clothing, and/or household supplies/furnishings due to a fire or some other man-made or natural disaster? Are you in need of emergency child care? If yes, what is the reason for the emergency? Are you in need of emergency transportation? If yes, what is your destination and transportation need? Are you in need of emergency medical care? If yes, what is your medical emergency? 29

30 SECTION XXI - N-CUSTODIAL PARENT INFORMATION Are there children in this household who have a parent who does not live with them? If yes, complete the chart on the following page: CHILD S NAME N-CUSTODIAL PARENT S ADDRESS MARRIAGE DATE ABSENCE DATE NAME: / / / / SSN: NAME: / / / / SSN: NAME: / / / / SSN: NAME: / / / / SSN: NAME: / / / / SSN: Good Cause Claimed for not cooperating with Child Support Enforcement? Non-Custodial Parent s Place of Employment: Non-Custodial Parent s Wages: $ Is the Non-Custodial Parent(s) Court-Ordered to provide medical support? SECTION XXII - LEGAL GUARDIAN/PROTECTIVE PAYEE/AUTHORIZED REPRESENTATIVE Does anyone in your household have a legal guardian, power of attorney (POA), or committee? If yes, complete the following: Name: Address: Telephone Number: Does your household have a protective payee (substitute): If yes, name of protective payee? Address: Telephone Number: Does your household have an authorized representative? If yes, name of authorized representative? Address: Telephone Number: 30

31 SECTION XXIII - MILITARY SERVICE RECORD Is or has anyone in your household been in the Military? If yes, complete the chart on the following page. If no, please go to the next section titled Potential Resources. Name: Serial Number: Branch: Service Disability: Date of Service: From: To: Name: Serial Number: Branch: Service Disability: Date of Service: From: To: SECTION XXIV - POTENTIAL RESOURCES Do you or anyone who lives in your household expect to receive any benefits or income, such as, but not limited to, Social Security Benefits, Wages from Employment, Unemployment Benefits, Child Support or Insurance Settlements that you are not now receiving? 1) If yes, Who? Type: Expected Date of Receipt: 2) If yes, Who? Type: Expected Date of Receipt: To: To: Applicant s Signature Date Worker s Signature (Worker Who Interviewed Client) Date Co-Applicant s Signature Date Worker s Signature (Worker Who Interviewed Client) CASE COMMENTS: (For Office Use Only - DO T WRITE IN THIS AREA.) Date 31